Calderdale and Huddersfield NHS Foundation Trust

7. Mr A complains about aspects of the care he received from the Trust between December 2022 and December 2023. He specifically complains the Trust:

• did not carry out surgery until 13 days after it admitted him • discharged him in early January 2023 without an appropriate support plan in place • did not manage his pain appropriately and failed to provide medication information to his GP • did not recognise he had complex regional pain syndrome and refer him appropriately to the pain management clinic. CPRS is a chronic pain condition usually affecting a limb after injury or trauma.

8. Mr A said the delay caused him anxiety whilst in hospital. He considers the delay meant his leg did not heal correctly, causing prolonged post-operative pain.

9. Mr A said he has been traumatised by living with the pain with no support in place. He struggled to function on a daily basis. He said he lost his job, his relationship and social life. As a result, he said he has suffered with anxiety and depression. It impacted on his communication and he developed a stutter.

10. Mr A said he has experienced ongoing pain and there were issues with his medication because of the poor discharge information shared with his GP. This caused further distress.

11. He said the delay in the referral to the pain management clinic led to a delay in him being diagnosed with CPRS and being treated appropriately. This meant he endured prolonged pain for nearly a year.

12. Mr A is seeking an apology, service improvement and financial remedy.

13. In December 2022, Mr A attended the Emergency Department (ED) at the Trust with a fractured ankle having slipped on ice.

14. The Trust reset Mr A’s ankle, X-rayed the ankle and put a cast on the leg. It told Mr A he would need to undergo surgery when the swelling on his ankle had subsided.

15. 13 days later the Trust carried out the surgery on Mr A’s ankle.

16. Six days later the Trust discharged Mr A home. There is no discharge summary in the records, which the Trust has acknowledged. A discharge summary is a document hospitals provide to the patient and GP when the patient is leaving the hospital. The discharge summary outlines their diagnosis, treatment, medications and follow up care instructions.

17. Five days after discharge, the Trust reviewed Mr A at the out-patient clinic.

18. At an eight week review, the Trust carried out an X-ray on Mr A’s ankle.

19. In December 2023, the pain clinic reviewed Mr A and diagnosed him with CRPS.

Delayed surgery

26. Mr A told us he attended hospital in December 2022 having fallen on ice. He said the Trust told him he would need to undergo surgery when the swelling subsided.

27. Mr A complains that the nurses told him daily he would be undergoing surgery, so they kept him ‘nil by mouth’ for repeated mornings, but later advised him that surgery would not be happening.

28. Mr A said staff left him in a cast for two weeks until the Trust arranged an actual date for surgery. He said no one checked for swelling during this time. He believes that being left in a cast for two weeks meant his leg started to heal incorrectly, putting pressure on his sciatic (a nerve that runs from the lower back to the feet) and other nerves resulting in significant pain.

29. The Trust said the orthopaedic team needed to wait until the swelling had gone down before repairing the fracture. It explained swelling can increase risks of complications such as poor healing. It said it is usual for this to take ten to 14 days.

30. The Trust said documentation indicated the swelling had improved 13 days later, and the consultant considered Mr A was ready for surgery. Prior to this, it said the team requested he was nil by mouth with the hope the swelling had subsided, and he could go straight for surgery with minimal delay. It said unfortunately the swelling had not gone down.

31. The Trust added the sciatic nerve is related to the hip and not the ankle joint and the delay in surgery had no impact on the outcome of the healing. It considered the fracture was successfully repaired.

32. NICE guidance NG37 says, ‘if treating an ankle fracture with surgery, consider operating on the day of injury or the next day’.

33. BOASt guidance says, ‘early fixation (on the day or day after injury) is recommended in the majority of patient under 60 years when the ankle mortise [the space in the ankle formed by the two bones of the lower leg] is unstable’.

34. We know Mr A attended the ED in December 2022 with a fractured ankle. The Trust X-rayed the leg, put a cast on it and told him he would need to undergo surgery when the swelling subsided.

35. Clinical records indicate for the following week he was nil by mouth in preparation for possible surgery. The Trust carried out the surgery 13 days later. We can see this more time than advisable under both NICE NG37 and BOASt guidelines.

36. We asked our orthopaedic adviser whether the delay between Mr A attending the ED and undergoing surgery was acceptable and in line with guidance.

37. They noted the significant delay between admission and ankle surgery of almost two weeks. However, our adviser told us it can be desirable to wait for seven to ten days before surgery if there is significant swelling. They identified records indicated there was concern about the swelling.

38. PubMed study (Konrad et al) says delayed surgery is an acceptable alternative when swelling is present because this is not an ideal situation for a surgical procedure. It says delaying surgery can minimise complications in severe ankle fractures.

39. We can see one ward round record, two days after Mr A attended the ED, which indicates staff checked Mr A’s leg and advised him that it would be a week to ten days for the swelling to subside. We cannot see any records to indicate staff checked for swelling any day thereafter.

40. Our orthopaedic adviser said it would not have been necessary to check for swelling on a daily basis because it would be unlikely for the welling to have gone down before seven days after the injury, as the Trust had explained to Mr A.

41. They agreed staff should have been checking for swelling if he was due to go for surgery. Records indicate Mr A was nil by mouth for seven days which suggests the Trust considered he could be in a position to go for surgery. It is unclear from records why surgery was cancelled on multiple occasions. There is a suggestion in the information we have seen that this could be due to lack of availability on the trauma list and availability of foot and ankle surgeons.

42. Our orthopaedic adviser considered on the balance of probabilities the surgery could have happened earlier if there was theatre space and an appropriate surgeon was available if the swelling was checked regularly a week after his admittance. Their view is that it is unlikely the delay of five days would have changed the outcome for Mr A.

43. We understand this must have been a difficult and worrying time for Mr A. He did not know what was happening and was in pain and discomfort.

44. Mr A had significant swelling, and we think it would not have been appropriate to carry out the surgery within NICE NG37 and BOASt guidelines. We understand it was appropriate to wait for any swelling to go down. We realise there also may have been additional reasons affecting the surgical list. We understand the difficulties facing surgical teams. Our view is the Trust should have checked Mr A’s leg if he was being prepared for surgery. It should have checked his leg for swelling and documented this at least seven days after the injury.

45. Our view is that the Trust did not act within NICE NG37 and BOASt guidance and we consider this to be a failing. We will discuss the impact further in the report.

Discharged without appropriate support

46. Mr A said the Trust discharged him home following a very brief physiotherapy appointment. He said he lives by himself and does not have any support. He complains the Trust did not provide him with adequate advice or complete a home assessment.

47. Mr A said he has been traumatised by living with pain without any appropriate advice provided or support in place. The pain impacted on his ability to carry out daily tasks, to meet his self-care needs and to do his job.

48. The Trust response referred to Mr A’s clinical records which documents the consultant referred him to the physiotherapy team the day after his admission. The physiotherapist reviewed him two days later. They taught him how to sit and stand with crutches and discussed his equipment needs.

49. The Trust said the physiotherapist reviewed him again after surgery and they documented a comprehensive social history. The physiotherapist then reviewed him regularly until the point of discharge ensuring he was able to go up and down stairs safely.

50. The Trust considered Mr A was safe when mobilising and there was no evidence to suggest he would not be able to manage at home.

51. Standard 8.3 of the Quality Assurance Standards for physiotherapy says there should be ‘evidence that information is collected to inform the physiotherapeutic process which, where appropriate includes: the service users demographic details, presenting conditions/problems history of the presenting condition including management of the problem to date, the service user’s perception of their needs, the service user’s expectation of intervention’.

52. We can see from the records a physiotherapist saw Mr A the day after his surgery. There is evidence of an assessment where the physiotherapist obtained information regarding Mr A’s social history and wider information in line with guidance.

53. We can see a physiotherapist saw Mr A daily on the ward for the next five days before discharge.

54. Our physiotherapist adviser said this was an appropriate level of assessment by a physiotherapist following a leg injury.

55. The Quality Assurance Standards further say, ‘on completion of the treatment plan, arrangements are made for discharge or transfer of care: the service user is involved with the arrangement for their transfer or care/discharge and offered copies of transfer or discharge summaries, arrangements for the transfer of care/discharge are recorded in the record, when the care of a service user is transferred, information is relayed to those involved in their on-going care in the most appropriate manner and format’.

56. The Trust has acknowledged there is no evidence of a discharge letter. This would be the responsibility of the ward doctor. It would be the role of the physiotherapist to arrange for the out-patient physiotherapy. We cannot see this referral in the records, but the Trust response indicate Mr A was referred for out-patient physiotherapy which he attended. It appears the GP arranged this.

57. We asked our adviser whether the Trust should have completed a home assessment, particularly given the fact Mr A lived alone without support. Information we can see the physiotherapist obtained in their assessment.

58. Our physiotherapist adviser said it would be usual for multi-disciplinary discussions to take place at handovers to address patient’s needs. They felt there was an omission with regards to this. They felt the discharge planning did not consider fully the bigger picture for Mr A.

59. We can see the Trust carried out a stair assessment. We cannot see indications that the Trust considered the wider implications for Mr A. The assessment noted he lived by himself, but there is no evidence of discharge planning considering how he might function on a day-to-day basis at home in terms of preparing meals and self-care whilst he was non weight bearing (using crutches).

60. We cannot see evidence to say the Trust adequately considered Mr A’s support needs at discharge.

Pain management

61. Mr A complained staff did not manage his pain appropriately whilst he was in hospital. He said he regularly had to ask for pain medication.

62. He also complained the Trust did not provide a discharge summary to his GP, so his GP did not meet his request for pain medication. He said his pain levels were extreme at the point of discharge, and it caused him great distress having to navigate this situation by himself.

63. Mr A said the Trust discharged him with a lot of drugs and strong painkillers. At the review appointment after discharge, he asked the consultant about his pain relief. The Trust told Mr A his GP would manage this as the details would be sent to them.

64. Mr A said the GP could not prescribe any pain medication because there was no record of the January appointment. He said he had to complain to the Trust before he could receive the pain medication.

65. Mr A said he was prescribed oxycodone, which he then took for nine months. Oxycodone is a strong opioid pain medication used for moderate to severe pain. He said no one reviewed his medication during this time. He explained he went through withdrawals whilst managing the pain and this was extremely difficult. He said he was then prescribed gabapentin which he found to be ineffective. Gabapentin is a medication used to treat nerve pain.

66. The Trust apologised for the times Mr A requested pain relief in the hospital. It said it had reviewed his medication chart and there was evidence he was given pain relief regularly and the team responded to his elevated pain by adjusting medication and increasing dosage. It said he was referred to the pain team who reviewed his medication.

67. Trust acknowledged there is no record of a discharge summary being completed. It apologised for not providing Mr A’s GP with important information following his discharge. It said this concern had been shared with the team to advise them to ensure discharge summaries are completed in a timely manner.

68. GMC guidance says: ‘you must promptly share all relevant information about patients (including any reasonable adjustments and communication support preferences) with others involved in their care, within and across teams as required’.

69. We have seen Mr A was provided with regular pain medication during his inpatient stay. There is evidence in the records Mr A was reporting extreme pain. We can see he was reviewed by the pain team at the beginning of January, and his medication was reviewed due to adverse side effects.

70. Our orthopaedic adviser did not identify any concerns regarding the pain management within the Trust.

71. Faculty of Pain Medication Guidance says, ‘patients discharged on opioids should be prescribed no more than 5-7 days medication depending on the surgical procedure’.

72. The guidance also states, ‘the discharge letter must explicitly state the recommended opioid dose, amount supplied and planned duration of use’.

73. There is no discharge summary with the Trust’s records, or the GP records. This means the GP would not have been provided with details around Mr A’s medication needs and follow up care instructions.

74. We can see from GP records that the GP made changes to Mr A’s medication record which includes the addition of oxycodone, eight days after Mr A was discharged from the hospital. Our orthopaedic adviser highlighted this was a significant dose.

75. We have not seen evidence to indicate the Trust shared medication information with the GP. Without evidence of a discharge summary in the GP records, and information to suggest the GP became aware of Mr A’s medication needs, we consider it is reasonable to think Mr A was likely without medication for a couple of days.

76. Mr A said he was given a few days’ worth of medication on discharge. He was then in a position where he was calling the Trust and the GP, trying desperately to sort out his medication so the GP could provide it. We can understand this must have an upsetting and challenging time for Mr A, particularly when he was feeling so vulnerable and in pain.

77. We think there were failings with regards to the Trust’s management of Mr A’s medication on discharge.

78. Once this information was shared with the GP, we do not think we can say the Trust did not manage Mr A’s medication appropriately thereafter.

79. Records indicate Mr A continued to take oxycodone for nine months after discharge. According to guidance, this is an inappropriate length of time for an individual to take opioid medication.

80. Our pain adviser told us following discharge, it would have been the responsibility of the GP to review medication, not that of the Trust. It said the orthopaedic appointments would be focussed on healing as opposed to pain relief.

81. However, we understand the Trust did not refer Mr A properly to the pain management clinic. This is discussed further in the next section. Had Mr A accessed the pain clinic sooner, we believe his medication would have been reviewed through this forum.

82. We understand once he attended the pain clinic, the consultant determined he had nerve pain, which is a strong component of CRPS and prescribed Gabapentin. Our pain adviser said this was appropriate medication to potentially meet Mr A’s needs. Mr A has said this was ineffective.

83. In summary, we think the Trust managed Mr A’s pain medication appropriately whilst at the Trust. We think it did not discharge Mr A appropriately, and this impacted on him accessing essential medication for up to eight days. We do not think the Trust was responsible for managing Mr A’s pain medication for the duration of that year. However, our view is there was a delay in Mr A accessing the pain clinic. The pain clinic would have reviewed his pain medication at an earlier point, had the referral gone through in a timely manner.

Chronic regional pain syndrome (CRPS)

84. Mr A complains the Trust did not refer him to the pain clinic promptly following discharge. He considers this delayed the diagnosis of CRPS. He said he had skins discoloration and ongoing pain which he informed the orthopaedic consultant about this at each review. He said this meant he was not accessing the appropriate treatment for nearly a year.

85. In its response, the Trust said it is not unusual for patients to suffer pain after an ankle fixation. It said the consultant identified the possibility of CRPS in April 2023 and made a referral to the pain clinic.

86. The Trust explained unfortunately at a review in September it was evident the pain clinic had not received the referral. It then took action to expedite this. Mr A was then seen in November where the pain clinic determined his symptoms fulfilled the criteria for CRPS.

87. RCP guidance says, ‘the CRPS diagnosis within the first few weeks after injury is difficult to secure, because signs and symptoms are often indistinguishable from normal variations to the post-injury or post-operative response. It is common for patients to have pain out of proportion to that expected for their injury, and the vast majority of these responses resolve’.

88. It goes on to say, ‘although CRPS an often not be reliably diagnosed before 4 weeks after injury, continuation of these symptoms may indicate that the patient is at risk to develop CRPS’.

89. It also says, ‘if CRPS is suspected the ED clinician should: exclude alternative diagnoses’.

90. We can see from the clinical records Mr A attended the orthopaedic clinic for reviews two weeks and six weeks after the operation.

91. He attended a further review in April 2023 and underwent an X-ray. He raised concerns about increased pain and nerve symptoms. The consultant made an urgent referral to the pain clinic.

92. Unfortunately, records indicate there was an issue with the referral being sent and we can see the Trust realised this at the September review and then expedited it. Mr A was seen at the pain clinic in November 2023 and diagnosed with CRPS.

93. Our pain adviser said it is unusual for a consultant to make a diagnosis of CRPS for at least a few months, and often up to a year after the injury or surgery. Firstly, it is necessary for the consultant to wait for the bones and tissue to heal completely before diagnosis. They also highlighted the guidance which says CRPS is made through a diagnosis of exclusion. This means the consultant has to consider other possibilities before reaching a conclusion of CRPS.

94. The RCP guidance indicates when a consultant has identified possible CRPS there should be an urgent referral to local CRPS pathways. We currently think the consultant identified CRPS and planned an urgent referral.

95. With the above in mind, we consider the four month period between the operation in December 2022, and the consultant determining a referral to the pain clinic was needed at the April 2023 appointment was within a reasonable time-frame, and in line with RCP guidance.

96. Unfortunately, there was delay of five months in the Trust sending the referral, which will have impacted on Mr A accessing the pain clinic. We understand Mr A continued to experience great pain during this time which was impacting on every aspect of his life.

97. We will consider the impact of this administrative error further in the report.

Impact

98. Mr A considers the delay in surgery impacted on the physical healing of his leg. He says this also added to the level of pain immediately after the surgery, and throughout the following year.

99. Mr A said he was prepped for surgery on repeated days, was nil by mouth, only be told later in the day surgery would not being going ahead. He said no one checked for swelling or explained the delay to him. He said this seriously impacted on his mental health over the time he was in hospital.

100. Mr A told us: ‘My life as I knew it was snatched away. Before the accident I was a company director and I used to regularly drive to London and back in a day for work. I am now only able to manage short distances of travel due to the pain and exhaustion I continue to experience. I now have a lifelong disability. Who I am now has changed irreversibly by the damage that has been caused including my mental health, energy levels and mobility. I developed a serious stammer and I couldn’t communicate with people. I became isolated and depressed. I was in horrendous pain for months’.

101. Firstly, we have considered the physical impact of the delayed surgery.

102. Pubmed peer reviewed literature indicates there to be minimal impact from delayed surgery as long as adequate reduction and stabilisation of the fracture is achieved, ‘ankle ORIF more than 14 days after injury did not significantly increase the rate of wound complication, nor did it impair ultimate functional outcome in this group’.

103. Our orthopaedic adviser also pointed to studies which highlight the difficult in achieving surgical fixation of ankle fractures within BOASt guidelines: ‘only 10% of patients underwent ankle surgical fixation in accordance with the BOASt and NICE guidelines, with the mean time for surgery from injury as 10.7 days for the remaining cohort, The association between BOASt and NICE compliance and complication incidence was found to be non-significant’.

104. We have seen the clinical letter dated February 2023 (three weeks after surgery) which does not indicate there were any concerns about the reduction and stabilisation of the fracture. Mr A was reported to be progressing well.

105. A further clinic letter dated September 2023 states, ‘I have seen Mr A today in the clinic for radiological and clinical assessment. He has achieved full union and all the scars are fully healed’.

106. Our orthopaedic adviser considered on the balance of probabilities the surgery could have happened earlier (if there were theatre space and an appropriate surgeon available) had staff checked the swelling and observed it had gone down. Their view is that it is unlikely the delay of five days would have changed the outcome for Mr A.

107. They said there is no evidence within the records to indicate the delay in treatment may have caused improper fracture realignment. Their view is the ongoing pain that Mr A evidently experienced was in relation to the CRPS which was later diagnosed. They cannot link the pain to the delayed surgery.

108. We realise how worrying and distressing it must have been for Mr A to be in hospital waiting for surgery. We understand his concerns that he was prepared for surgery daily which is evident records, only to be told it was not going to happen. We have seen no evidence to suggest staff checked his leg for swelling over this time.

109. We think the Trust should have carried out the surgery at least five days earlier. We cannot link the delayed surgery to the long-term physical impact Mr A suggests. We can say the delay caused Mr A distress and upset for the duration of the time he was in hospital. We also think it is reasonable to consider his distress and anxiety was prolonged because he continued to experience significant pain and linked this with his experiences in hospital.

110. We have identified the Trust did not discharge Mr A appropriately considering his support needs at home.

111. Mr A said he struggled on a daily basis to function. He lives by himself and did not have any support.

112. Our physiotherapist adviser highlighted Mr A was non weight bearing at the point of discharge, and would have struggled with daily tasks. The Trust was aware he lived at home alone and did not have support.

113. We think it is reasonable to consider Mr A would have struggled to manage daily tasks. This was at a time when he was in significant pain, and we also believe he was unable to access the medication he needed. We think it is likely this impacted further on Mr A’s distress after discharge.

114. We have next considered the impact of failings in the Trust’s management of Mr A’s pain and medication.

115. The Trust has acknowledged the lack of a discharge summary. Without this, the GP would not have known what medication Mr A needed. It is reasonable to consider Mr A experienced increased pain if he was unable to access the pain relief he needed.

116. We also consider it likely this situation would have contributed to Mr A’s feelings of upset and distress. He was in pain, in a vulnerable situation, without support and needed to negotiate between the Trust and the GP about his medication. We think we can link this failing with regards to the discharge with the anxiety and upset Mr A has told us about.

117. Whilst we consider it was the GP’s role to review Mr A’s medication thereafter, we consider the delay in referring Mr A to the pain clinic, resulted in a missed opportunity for the pain clinic to review Mr A’s medication also. This meant he continued to take oxycodone for longer that he would have done, had the pain clinic referral gone through in a timely manner.

118. We know Mr A has expressed concerns about the addictive nature of opioids and the impact this had on him mentally. We think the GP should have been reviewing these medications with Mr A and considering the side effects these medications had on Mr A over this time.

119. In terms of the effectiveness of Mr A’s pain medication, our pain adviser said the medication issues would not have impacted on Mr A’s experience of pain. He had been taking the oxycodone for a prolonged period of time, before trying gabapentin. Neither were effective. Our pain adviser explained there is no alternative medication for CRPS, or any evidence that analgesic drugs can prevent its development. They explained in terms of pain relief and CRPS, Mr A’s outcomes would not been better or worse with or without the oxycodone.

120. We then considered the impact of the delay in Mr A accessing the pain clinic.

121. We think the Trust considered the possibility of CRPS and referred Mr A to the pain clinic in a time-frame in line with guidance. However, there was evidently an administrative error which meant the referral was not sent until five months later. This error undoubtedly impacted on Mr A accessing involvement from the pain clinic.

122. RCP guidance says, ‘it is very unlikely that CRPS pain after your injury could have been prevented. The right diagnosis and treatment can reduce suffering from CRPS pain’.

123. Our pain adviser said the delay in the referral to the pain clinic would not have prevented the development of CRPS, early diagnosis does not change how CRPS will evolve. They explained the recommendation for early referral to CRPS pathways is to try and improve the impact of CRPS.

124. The RCP guidance says, ‘treatment aims to improve your quality of life, function and reduce pain. It is likely that you can get some pain relief with treatment, The success of some treatments depends on the amount of effort you put into them’.

125. Our pain adviser explained to us that earlier treatment in terms of rehabilitation support such as physiotherapy and exercise can provide better symptom relief. They said this can be dependent on the person and the pain they are experiencing. Their view was it is not possible to say definitively whether the treatments would have offered Mr A significant relief from the pain he was experiencing.

126. The RCP guidance also refers to pain relief through medication and says, ‘drugs can sometimes reduce CRPS pain’.

127. Our pain adviser noted Mr A was already taking oxycodone. It is evident from records and Mr A’s account that this was not an effective form of pain relief for him. They said this is the strongest pain relief available, and the pain clinic would not have been able to prescribe an alternative which would have been more effective.

128. Overall, they said the natural history of many patients with CRPS is that they improve in the first 13 months, which psychological and therapeutic strategies being helpful to some patients but not all.

129. We think the Trust did not refer Mr A to the pain clinic in a timely manner due to an administrative error. We cannot say how Mr A and the pain he experienced would have responded to any earlier intervention from the pain clinic. We can say he should have accessed support earlier, and it may have been effective.

130. We consider is reasonable to think, this delay added further to the distress and anxiety Mr A was feeling. He was unable to function on a daily basis and was desperate for some support to manage his pain. From Mr A’s GP records, we can see he had previous mental health vulnerabilities. We think we can link the delay in sending the referral to a further deterioration in Mr A’s mental struggles. We also think the Trust missed an opportunity to enable Mr A to access support that may have reduced the pain he was experiencing.

1. We are sorry to hear about Mr A’s experiences in hospital and the prolonged pain he has experienced since discharge. We do not underestimate how significantly pain can impact on every aspect of life.

2. We have carefully considered Mr A’s complaint about delayed surgery. We cannot link the ongoing pain he has experienced with the Trust delaying surgery. We also think the Trust managed Mr A’s pain medication adequately in hospital.

3. We have seen the Trust did not discharge Mr A appropriately or in line with guidance. We provisionally think it did not ensure appropriate support was in place or share information about his pain medication with his GP. We have also seen delays in the Trust referring Mr A to the pain clinic.

4. We think the failings by the Trust in terms of discharge and a timely referral to the pain clinic impacted on Mr A. We think it likely meant Mr A experienced prolonged pain, which in turn impacted on his emotional and mental wellbeing. We think it is reasonable to consider the pain and the emotional health issues effected Mr A’s quality of life.

5. We partly uphold Mr A’s complaint.

6. Therefore, we ask the Trust to write to Mr A to acknowledge the failings in the service provided and to apologise. We ask the Trust to complete an action plan stating how it will improve its service where we have identified failings. We also ask the Trust to pay Mr A £1,200 in recognition of the impact the failings have had on him.

131. For the reasons set out above we will partly uphold Mr A’s complaints.

132. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

133. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

134. To assist us in considering an appropriate level of financial remedy we use the severity of injustice scale (our scale) from Our Principles for Remedy. We also refer to previous cases where we have made similar recommendations.

135. Our scale allows us to ensure the recommendations we make are consistent and transparent for everyone who uses our service. The figures included in the scale represent the Ombudsman’s judgement about the sort of sums that are both appropriate and proportionate for us to recommend. The scale contains six different levels of injustice that a complaint could fall into, which increase in severity. Each level is then linked to a range of the financial amounts we would usually recommend in those circumstances.

136. We have identified the Trust did not carry out surgery within guidelines, did not discharge Mr A adequately or in line with guidance in terms of medication and home support. We have also seen a delay in the Trust’s referral to the pain clinic.

137. Level 3 on our Scale includes cases that had an impact on the person affected which has been experienced over a significant period of time. We can see there was an 11 month period between Mr A being discharge from hospital and accessing the pain clinic.

138. We currently cannot link the delayed surgery with the ongoing physical pain. We also do not know how Mr A would have responded to interventions recommended by the pain clinic, but we think the Trust missed an opportunity to enable him to access support earlier.

139. We have seen the Trust did not provide the GP with discharge information. We have also seen failings with regards to the discharge and the assessment of Mr A’s needs. We cannot hold the Trust wholly accountable for the medication concerns after the GP was provided with the medication information.

140.   We think we can link the impact of Mr A’s experiences with the Trust with a deterioration in his mental health and wellbeing. We think it is reasonable to consider the failings by the Trust would have caused him distress and anxiety.

141. We think the impact we have seen in this case fits with the higher end of level 3.

142. We are partly upholding Mr A’s complaint so we will ask the Trust to write to Mr A to acknowledge the failings and the impact we have identified, and to apologise for this. We would ask the Trust to do this within two months from the date of our final report.

143. Our complaint standards say, ‘staff recognise the need to be accountable for their actions and to identify what learning can be taken from a complaint. They are clear about how the learning will be used to improve services and support staff’.

144. In line with this, we recommend the Trust produces an action plan to show how it will ensure the failings we have identified are not repeated. The failings we have identified are the Trust: • the Trust did not carry out surgery in line with guidance or sufficiently explain the reasons for the delay to Mr A • did not complete and share a discharge documentation with the GP • did not ensure Mr A’s needs were met in the discharge planning • failed to send a referral out in a timely manner.

145. The action plan should include a clear timeline of the steps it will take, as well as an explanation of who will be responsible for the implementation.

146. Following this review, our current thinking is the organisation should pay Mr A £1,200. This is in recognition of the distress and anxiety Mr A experienced over a period of time, and the potential loss of opportunity for a better outcome.

147. We are sorry to hear about Mr A’s experiences since his accident. We understand how pain can impact on an individual physically and mentally. We hope the pain lessens over time to enable him to live a full life.